The first in a series of articles designed to share results based on a 5 year research project that looks at threats we are exposed to daily and the risk to our health.

1. [MULTIDRUG-RESISTANT ORGANISMS (MDRO’S), UNPLANNED
PREGNANCY AND SEXUALLY TRANSMITTED DISEASES, A
By Terri Embry-Street RN BS BEHAVIOR AND RISK MANAGEMENT CORRELATION]
Throughout my practice in Oncology, ICU, Home and Long-Term Care Infusion, I have been
exposed to some of the more vulnerable, at-risk patients. Many have required intravenous antibiotic
therapy to treat life-threatening infections. Each of my encounters with patients, and their support
systems, afforded me with the opportunity to learn, educate, and provide solutions to care challenges.
Five years ago I began a journey to find infection prevention options to avoid bringing deadly germs into
my own home. I was seeing more and more patients with resistant organisms and I was exposing my
family to additional health risk if I brought them home. I began my assessment in different settings
encountered throughout my work and personal activities to see what practices were in place. It
developed into a research project on behavior, decisions and what impacted both.
Infectious organisms, their biofilm protective environment, and products traditionally used to
control antibiotic resistant pathogens have proven unsuccessful, with respect to containment, and even
less so with respect to eradication. All the while, global sustainability efforts are fighting for a place at
the decision table and healthcare cost containment is a necessity. My research objective evolved to
include evaluating Infection Prevention and Sustainability recommendations related to all environments
with which a patient comes into contact and evaluate perceptions of risk. The goal was to correlate the
impact of decisions by companies and personal behaviors, on our health and quality of life.
The topic of combatting deadly germs led me in many directions with vast amounts of
information to discern. It became evident that the consequences of failing to change behavior were no
longer going to impact only those that took risk during sexual encounters. Invisible infectious microbes
are sharing resistance traits and are passed person to person and on contact surfaces everywhere.
Evidence has shown that those harboring colonies of MDRO’s are without symptoms and remain
colonized for weeks, months or years. I wanted to better understand what impacted decisions to
minimize risk and evaluate past efforts related to changing risk taking behavior, such as those focused
on reducing unplanned pregnancy and sexually transmitted disease.
These five-years of research included both passive (observation) and active (interviewing multiindustry leadership professionals, employees, my family and my friends) studies of the multi-faceted
topic. Considering all aspects likely to impact a patient’s healthcare experience became a personal
mission. Throughout the risk assessment I researched hand hygiene, cleaning and disinfecting behavior,
levels of understanding and what considerations were made, at home and places of employment. And,
as I studied products used to clean and disinfect I became more fearful of the health risk from exposure
or use of these chemicals than I was of the germs, themselves.
During this same time period, I began evaluating organizations interested in expanding the
knowledge and improving the health of the general public. This knowledge-base includes the elimination
of harmful germs and/or a reduction in the amount of potentially harmful chemicals. I found gaining
approval to test safe, new technology against products containing more hazardous chemicals in several
industries, both eye-opening and frustrating. As I traced decision making practices and the obstacles for
including these new products, process and monetary challenges were revealed. These included such
obstacles as old regulations, which were written with good intentions and more relevance when they
were implemented, did not allow for a new generation of solutions and technology. They had been
embedded into policy and procedures, effectively guiding practice. They also did not allow for
October 2013
sdcsconsulting@gmail.com
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2. [MULTIDRUG-RESISTANT ORGANISMS (MDRO’S), UNPLANNED
PREGNANCY AND SEXUALLY TRANSMITTED DISEASES, A
By Terri Embry-Street RN BS BEHAVIOR AND RISK MANAGEMENT CORRELATION]
incorporation of health hazards later identified that demanded consideration. The relationships and
time restraints throughout the supply-chain tended to exclude valuable introductions of new tools, thus
limiting access to all available options. Much like medication contraindications, chemical
incompatibilities were not always well understood, thus not made part of the decision process.
Many levels of government, large industries, and small businesses have joined healthcare
professionals in an attempt to better understand infectious pathogen containment. In the era of
information technology, the mounds of data and the growing number of organisms resistant to
treatment are both overwhelming. I found stark differences between knowledge of the leadership of
special focus groups dealing with all of the above issues in contrast with the majority of people being
exposed, as they focus on their daily tasks. But when questions were posed related to personal
behavior, I found a common thread between multi-drug resistant organisms (MDRO), unplanned
pregnancy and sexually transmitted diseases; it is, simply denial. Especially since everyone I questioned
admitted to seeing news stories related to the existence of germs which can cause loss of limbs or taking
of human life. It appeared that the belief that any infectious organism could have a significant and quite
negative impact on one’s financial, emotional and physical existence was not the issue. The obstacle
was getting people to understand, and accept, that these organisms do not discriminate and that it can
“happen to them and their immediate family”. Much like a biofilm covering microorganisms allow the
germs to live in their own “little world”, “it won’t happen to me” allowed most to live in theirs as well.
Ninety percent of those being interviewed had at least one experience with the health care
system personally or with a loved one. I never heard anyone claim to not believe the news stories, and
most appeared to have empathy for those who were adversely affected. Personal behaviors, at home
and throughout their daily routines, to minimize their risk, again, contained similar findings. Most
interviewees adapted to purchasing or using antibacterial soap or gel but could not articulate current
recommendations for their use. A small percentage recalled something about antibacterial soap
contributing to the antibiotic resistance issue, and most understood that not taking all of their
prescribed antibiotics could, as well. They also admitted thinking about hand washing and hand gel use
more often when interacting with the healthcare setting, raw meat or using public restrooms. As
restaurant patrons, they were least likely to perform hand hygiene before eating. And, with respect to
personal hand hygiene, environmental controls at home or their place of work seemed minimal at best.
Additionally, their cars, cellphones, credit cards and under their finger nails were not on the list of
frequently cleaned items or places. I could only find a small percentage of consumers that clearly
understood cleaning versus disinfecting their environment and that the latter required specific wet
contact times in order to be effective.
Most groups and individuals interviewed were unaware that the labels on products they are
exposed to do not fully disclose, or explain, all of the ingredients (active and inert) to allow them to
make a reasonably informed decision. The fact that there existed a likelihood of chemical insults to their
health through respiratory and skin absorption seemed to be the most shocking discovery of this
category. When I asked healthcare workers at all levels if they knew some resistant organisms, such as
October 2013
sdcsconsulting@gmail.com
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3. [MULTIDRUG-RESISTANT ORGANISMS (MDRO’S), UNPLANNED
PREGNANCY AND SEXUALLY TRANSMITTED DISEASES, A
By Terri Embry-Street RN BS BEHAVIOR AND RISK MANAGEMENT CORRELATION]
Clostridium difficile and Norovirus, are not killed by alcohol based-sanitizers, their facial expressions
were that of confusion and disbelief.
I have come to the realization that extremely harmful chemicals adding to the unsuspecting
body burden of our most vulnerable is an ongoing occurrence. Much like infectious organisms, the
chemicals do not discriminate. I contemplate if the financial impact of these chemicals on our
healthcare system were quantified, would it invoke change similar to nicotine. Using knowledge gained
from my studies in marketing, I traced product content on the labels to discover the differences
between the marketing message and actual “safety”. One of the most difficult tasks proved to be
finding an accurate Materials Safety Data Sheet instead of the “marketing version” of that information. I
traced active and inactive ingredients through databases that included: Environmental Protection
Agency (EPA) Pesticide List, National Priorities List (NPL), State-Designated Priority List, Occupational
Safety and Health Administration, National Healthcare Safety Network, and the Agency for Toxic
Substances and Disease Registry to name just a few.
I decided to reflect on both personal and professional lessons learned that might reveal actions
to consider. The similarities between preventing infectious organisms, unplanned pregnancy and
sexually transmitted diseases (STD’s) lead me to consider historically used education methods and to
what degree they impacted people’s behaviors. What new element could be added for greater success,
related to MDRO’s? I recalled working as a new nurse on an Oncology Unit in the early 90’s when
Universal Precautions were being implemented. Some of the more experienced nurses did not want to
use gloves during patient care, and some resisted the measure even for IV sticks or lab draws. When
asked why they felt this way, their responses indicated that they felt it was impersonal and insulting to
the patients. Most felt as if they were saying, “I believe you might have HIV”, therefore I must take
measures to protect myself from you. Many nurses would actually tear the index finger off of the glove
so that they could assess the veins during venipuncture. Years later, Universal Precautions have become
routine and I could not find a trace of the old mentality related to insulting the patients. So I posed the
question, “How do we shorten the time-frame between exposure to new threats, new regulations
implemented to protect us all from these threats and a degree of acceptance that positively, and
consistently, impacts behavior?”
As a young girl, I had a front row seat as a spectator watching my mother in the healthcare
system as she received treatment for complications related to being a brittle diabetic. She performed
home peritoneal dialysis and eventually received a renal transplant. Our entire family participated in
protecting her by strictly adhering to infection prevention advice. Witnessing my father’s due diligence
to learn how he could advocate for her and prevent harm started my personal passion to improve the
education of those entrusted to care for our loved ones. Additionally, I have heard woman admit to
allowing unprotected intercourse for fear of offending their partner, who shared the mentality of “it
won’t happen to me”. The men would not use a condom complaining it reduced the sensation or
overall experience. The simple act of using a condom for protection from sexually transmitted diseases
or unplanned pregnancy is ignored; why? What do we hope to learn as a result of having spent millions
October 2013
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4. [MULTIDRUG-RESISTANT ORGANISMS (MDRO’S), UNPLANNED
PREGNANCY AND SEXUALLY TRANSMITTED DISEASES, A
By Terri Embry-Street RN BS BEHAVIOR AND RISK MANAGEMENT CORRELATION]
of dollars and many educational campaigns designed to heighten awareness of these subjects? What
behavior will change now that the Center for Disease Control published, Antibiotic Resistance Threats in
the United States, 2013? Germs resistant to treatment were listed in three distinct threat categories,
“Urgent, Serious and Concerning”. One of the top three organism threats listed as “Urgent” is DrugResistant Neisseria gonorrhea. Now that drug resistance and sexually transmitted diseases are one in
the same concern, can we expect to see change follow? How soon? Will fear of what body part is
infected create changed behavior? Is it possible patients are afraid to tell healthcare workers to wash
their hands before providing care for fear of insulting them even though it puts their lives in peril?
The financial costs of treating those affected by any of these issues are staggering and even
without the actual mortality rates, emotional factor of such a life altering event or fear of personal
impact, one would hope to see change invoked. Those not routinely washing their hands and cleaning
high touch areas had wrapped themselves in a layer of denial that events on the news could not seem to
penetrate. Additionally, the strong smell of chemicals seemed to give people a false sense of safety,
cleanliness and health. The high percentages of asymptomatic, MDRO-colonized people interacting in all
segments of life can immediately recontamination a surface with one touch. And, although the
leadership and committees approached were working hard to implement change, I found processes to
introduce new EPA approved solutions as difficult to penetrate as biofilm and denial. As I traced
pesticide use regulations for different industries and their state license requirements, whether I
reviewed nail salons, or the food industry, I found the need for wording to allow a decision based on
human and environmental health. Many federal regulations exist to protect our health in most
industries but state and corporate documents, as well as practice do not reflect them. The supply chain
for services and products that affect infection prevention, and health safety, should be evaluated to
ensure decision makers have access to the safest options.
Two simple acts and one important consideration could have a profoundly positive impact on
society; hand hygiene and high touch environmental care, and the use of products that meet the Center
for Disease Control, Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, Properties
of an ideal disinfectant. Products that claim to be “non-hazardous” which have been proven to contain
harmful and/or unnecessary ingredients should be avoided, at all cost. Implementing these measures
would dramatically reduce healthcare cost, loss of productivity and improve student attendance. If
information from the Agency for Toxic Substance and Disease Registry were given more consideration at
the decision table, quality of life would be improved and lives saved.
Another component of the research included tracing the life cycle of household and industrial
cleaning and disinfecting chemicals. Many of the chemicals require evaluation of air quality; have
maximum exposure limits and their incompatibility with certain metals and other chemicals demand
consideration. Most require rinsing with “potable water” before human contact. Ultimately, I wanted
to find an option that I would feel comfortable recommending to patients without concern of causing
more harm to them; the equipment relied upon for treatment, or those in their environment. The
perfect product I was searching for would not require hazmat to be called if it spilled. This search led me
October 2013
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5. [MULTIDRUG-RESISTANT ORGANISMS (MDRO’S), UNPLANNED
PREGNANCY AND SEXUALLY TRANSMITTED DISEASES, A
By Terri Embry-Street RN BS BEHAVIOR AND RISK MANAGEMENT CORRELATION]
to Steven Brandon, CEO at Bioburdon Solutions Group and a product called Pure Hard Surface
Disinfectant & Sanitizer. It met all of the CDC’s ideal disinfectant criteria, was EPA approved, did not
require rinsing, and had 24 hour residual protection. The manufacturer, Pure Bioscience was focused on
food processing and high density environments such as correctional facilities and schools. I saw a
solution to the growing infection prevention issues and sustainability initiatives, and not just for one
industry. Bioburdon Solutions Group retained my consulting services to evaluate several industries, with
a strong focus on pediatric hospitals. I consulted with an environmental services department for a
major health system for almost a year. I learned that Pure Hard Surface Disinfectant and Sanitizer
outperformed the hazardous chemicals they were using and they challenged the 24hr residual as well.
The product strength available to consumers is also available commercially. Pure passed the efficacy
and safety test but did not replace the old technology, so again I evaluated behavior and decision
making to pinpoint where change could take root.
Staying up to date on the latest infection trends and the precautions industry leaders need to
implement can be overwhelming. Processing the changes that would be required to operations in
different settings associated with the changes seemed daunting but absolutely necessary. Healthcare
providers and first responders can’t simply treat one issue or take one person in the household into
consideration. Transmission is direct and indirect contact with infected people or surfaces. We must
take the entire environment, the human and pet elements and where they go during the day into
account when providing education. The basis for this education need includes, two-thirds of healthcare
associated infections are caused by 6 MDRO’s, with 1 category having a 50% mortality rate. Another
important resource is, Persistence of micro-organisms on common hospital surfaces Strategies to control
their dissemination , published by A. Neely, PhD. They were found to survive on polyurethane,
polyethylene, polyester, cotton and blends ranging from 12 hrs to >90 days depending upon the strain.
The association that guides practice related to infection prevention published Infection Prevention and
You to help consumers understand the issues and what role they have in prevention.
After presented education and my assessments to small and large groups, product evaluation
committees, not-for-profit and private organizations. I also attended conferences and held focus groups
with the intent being to assess behavior versus beliefs, and changes that may or may not occur after
education was provided. I evaluated their acceptance of the information presented and attempted to
ascertain what made one person receptive while another was not. In my professional opinion, the
organization’s culture, and an individual’s personality and personal exposure to healthcare seemed to
play a significant role. Infectious pathogens are opportunistic and demand our attention at a critical
time in healthcare which leaves no room for denial.
Industries, organizations and/or settings evaluated
Healthcare: Acute-Care Hospitals; Long-Term Care and Rehabilitation Facilities; Environmental Service
Companies; Mental Health Facilities & Residential Homes; Outpatient Surgery Centers & Infusion
Centers; First Responders, Fire and EMT; Wound Care Clinics; Physical Therapy Practices; Physician
October 2013
sdcsconsulting@gmail.com
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6. [MULTIDRUG-RESISTANT ORGANISMS (MDRO’S), UNPLANNED
PREGNANCY AND SEXUALLY TRANSMITTED DISEASES, A
By Terri Embry-Street RN BS BEHAVIOR AND RISK MANAGEMENT CORRELATION]
Offices; Urgent Care Centers; Radiology Centers; Outpatient Laboratory; Home Care Agencies; Home &
Long Term Care Infusion Providers; Durable Medical Equipment & Oxygen Providers; Dental Offices
Food, Service & Hospitality: Restaurants; Hotels; Janitorial Services; Catering Companies; Grocery
Stores; Nail & Hair Salons; Spas Education: Public & Private Schools & Sports Programs; Church and
Public Day Care Centers; Colleges, Technical Institutes; Pet Care: Veterinarian Offices; Boarding &
Grooming Facilities Private Homes: Maid Services; Rental Management Companies; Home Care &
Hospice Patients; Patient Support Caregivers Additional Organizations: Healthcare Without Harm;
Practice Green Health; Risk Management Society; Infectious Disease Society; LEED Green Building;
Green Schools Initiative; National Academies, Network of Emerging Leaders in Sustainability (NELS),
Association of Professionals in Infection Control and Epidemiology, Infusion Nurses Society, Alliance of
Nurses for a Healthy Environment
October 2013
sdcsconsulting@gmail.com
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